Stony Brook University Hospital Roslyn Heights, New York, United States
Disclosure(s):
Simon Lukose, DO: No financial relationships to disclose
Introduction: Immune checkpoint inhibitors (ICIs) such as pembrolizumab are increasingly used in oncology and are associated with endocrinopathies. Adrenal insufficiency and adrenal crisis are rare but potentially life-threatening complications that can occur early in the treatment course.
Case Description: A 63-year-old woman with metastatic mucinous adenocarcinoma of the appendix, previously treated with chemotherapy, was enrolled in a clinical trial and was initiated on pembrolizumab. Approximately three weeks after her first dose, she presented to the emergency department with weakness, fatigue, nausea, and vomiting. In the emergency department, her blood pressure was 96/65 mmHg and heart rate was 115. Laboratory evaluation revealed hyponatremia (Na 134 mmol/L), hypoglycemia (49 mg/dl), and acute kidney injury. Given the clinical concern for adrenal crisis secondary to immune checkpoint inhibitor use, she was started on intravenous hydrocortisone and IV fluids, with improvement of her symptoms and vitals. However, her hospital course was complicated by a small bowel obstruction and spontaneous bacterial peritonitis, and she expired several days after.
Discussion/
Conclusion: This case highlights an early presentation of adrenal crisis occurring within weeks of pembrolizumab initiation. The estimated incidence of secondary adrenal insufficiency and primary adrenal insufficiency is 1.1% and 0.8%, respectively, for patients treated with pembrolizumab. Most reported cases of immune check point-induced adrenal insufficiency occur after several months and multiple cycles of initiating therapy, typically three to six months into therapy. Although biochemical confirmation of adrenal insufficiency was not made for this patient, their clinical presentation was highly suspicious for adrenal crisis. Clinicians should maintain a high index of suspicion of adrenal insufficiency and initiate prompt therapy with steroids, even after a single dose, as rapid recognition and treatment are critical to prevent morbidity and mortality.
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